Laserfiche WebLink
■ <br /> RECEIVED BY EHD VIA EMAIL: <br /> 2/23/2022 <br /> Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair E 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181331 1/28/2021 <br /> Facility Name <br /> AP - B I LLJAR VALERO <br /> Facility Address 153 E. 11TH STREET ��tyTRACY, ZIP Code <br /> CA 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the TestPhone <br /> AFFORDA TEST 209-744-0112 <br /> Mailing Address4162ND STREET GALT, CA 95632 <br /> Service Technician Performing Test ZANE NIMMO <br /> Contractor/Tank Tester License Number04-1676Ex. 3/31/22 <br /> ICC Number ICC Expiration Date <br /> 8883064-UT 6/1/21 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling - EBW & Phil Tite #10009843708 Ex.11/30/2022 <br /> OPW#104-632 Ex. 3/15/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> LAKE TESTING SPILL BUCKET , DRAIN VALVE AND ADAPTER <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that each spill container was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.1; that required supporting <br /> documentation is attached; and all information contained herein is accurate. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Siqnature Date 1/28/2021 Total# of Pages <br /> 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />